Date of Drop off
Full Name
Address
Contact Phone where you can be reached TODAY?
Cell Phone
E-mail
Pet's Name
Species Canine Feline Avian Exotic
Pet's Breed
Photo of your pet
Pet's Age
Sex --- Male Female
Weight
Is your pet on any medication(s)? --- Yes No
If Yes, please state which medication(s)
Is your dog on heartworm prevention now? --- HeartGuard Interceptor Sentinel Other None
Last date purchased
Is your cat an --- Indoor only cat Outdoor only cat Indoor and outdoor cat
Is your cat on heartworm prevention now? --- HeartGuard Interceptor Sentinel Other None
Last date purchased
Has your cat been tested for Feline Leukemia? --- Yes No
If Yes, approx date?
Please check the requested treatments below Rabies Vacine Bordetella DHPP Influenza Leptospirosis Vaccine Leukemia Vaccine FVRCP Feline Leukemia Test Annual Wellness Lab Work with Heartworm Test Other Labwork Fecal Test Heartworm Test Only Radiograph Deworming / IPT Medicated Bath Sedation Other
Specific Labwork / Other, please state
Choose all that apply Vomiting Diarrhea Listless
If selected, how Long?
Appetite --- Decrease Increase
If so, how long?
Thirst --- Decrease Increase
If so, how long?
Urination --- Decrease Increase
If so, how long?
Litterbox --- Decrease Increase
If not using, how long?
Please check all that apply Coughing Gagging Congestion
If yes, how long?
Discharge? (check all that apply) Eyes Noes Ears
If yes, color, odor and how long?
Shaking Head? --- Yes No
Choose all that apply Limping Scratching Skin Irritations
If yes, location, and how long?
